and at both 1 and 2 years after the ACL reconstruction (Arundale et al., 2017; Arundale et al., 2018a; Arundale et al., 2018b; Capin, Khandha, Zarzycki, Arundale, et al., 2018; Capin, Zarzycki, et al., 2017, Capin, Zarzycki, et al., 2019; Johnson et al., 2020). However, female athletes after ACL reconstruction and
rehabilitation who engage in 10 additional sessions of strength, plyometric, agility, and secondary prevention exercises (with and without perturbation training) may achieve superior outcomes compared to those who engage in criterion-based rehabilitation.
Figure 9: Star Excursion Balance Training
Note . From Western Schools, © 2018.
Plyometric exercises Plyometric training refers to quick and powerful movements that involve quickly stretching the muscle-tendon unit during an eccentric maneuver to produce a subsequently stronger muscle contraction during a concentric maneuver (Chmielewski, Myer, Kauffman, & Tillman, 2006). These types of exercises are widely designed to resolve postinjury neuromuscular impairments, increase muscle strength and power production, and prepare patients for rapid movements and high-force production needed during high-level activities (Myer, Ford, McLean, & Hewett, 2006). Plyometric maneuvers constitute a natural part of most sport movements and involve double- and single-limb jumping, hopping, and skipping activities (Paterno et al., 2004). In clinical
practice, plyometric exercises are integrated into rehabilitation programs to bridge the gap between traditional rehabilitation exercises and sport-specific activities that include explosive movements (Cordasco, Wolfe, Wootten, & Bigliani, 1996). One example of plyometric exercise typically incorporated into postoperative rehabilitation is hopping. Hopping exercises progress from double- legged support (i.e., jumping) to single- legged hopping as the patient gains strength, control, and confidence. Single-legged hopping can include hopping up and down on a step (Figure 10), lateral hopping, and skating, where a patient stands on one leg and hops sideways with a soft, deep, and steady landing on one leg, and then hops back on the other leg (Eitzen, Moksnes, Snyder-Mackler, & Risberg, 2010).
Figure 10: Plyometric Exercises
Note . From Western Schools, © 2018.
Plyometric exercise is typically implemented in later phases of ACL rehabilitation to prepare athletes for return to their desired activity levels. Plyometric exercises may be initiated for patients who can tolerate moderate loading during strengthening exercises and perform functional movements in a proper pattern (Chmielewski et al., 2006). Plyometric exercises are initiated at low levels of intensity and then progress to higher intensity levels when patients are confident with the task and have tolerated previous intensity levels well. Progressing through the levels of difficulty of plyometric exercises is guided by the absence of adverse responses such as joint pain or joint swelling, as shown in Table 3 (Chmielewski et al., 2006). When performing exercises
that require single-legged landing, patients are instructed to land while maintaining proper knee alignment over their toes, with a soft landing to avoid further joint damage (Palmieri-Smith & Thomas, 2009). Plyometric exercises are incorporated into reinjury prevention programs to improve the neuromuscular and biomechanical characteristics of injured athletes (Myer et al., 2006). In addition, plyometric training has been found to significantly minimize the incidence of injury in female athletes when augmented with dynamic stabilization training (Mandelbaum et al., 2005; Myer, Ford, Palumbo, & Hewett, 2005).
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